Background & Aims

The opioid crisis in America has highlighted the need for robust Opioid stewardship within the NHS. Between 1998-2016 in the UK there was a 34% increase in prescriptions for opiates in primary care.

Appropriate opioid use can be very effective in managing acute & cancer pain. However, inappropriate use can cause harm. Chronic opioid use has been shown to predispose patients to poor surgical outcomes including immediate postoperative complications.

We discuss a novel pre-assessment triage pathway locally, identifying patients who are at moderate and severe risk of peri- and post-operative orthopaedic complications. Those patients are streamlined to further specific anaesthetic and pain optimisation prior to surgery. This involves multimodal drug rationalisation, and non-drug multi-disciplinary pain management strategies. This is in line with the Royal College of Anaesthetists Guidance on the Provision of Anaesthetic Services (GPAS) 2023 and resulting ACSA standards.

Methods

Data was collected by using a questionnaire given to patients in the orthopaedic pre op assessment clinic at University Hospital Plymouth, Derriford.

The questionnaire was designed to assess the patient’s use of analgesia by drug class, their functional status, their reported level of pain, and whether they had any diagnosed psychological disorder.

Patients were assessed for 4 weeks during April 2023. The questionnaire was administered face-to-face with pre-op assessment clinicians entering the participant’s responses onto the questionnaire sheet. Patient demographics were not recorded, and all information was kept anonymous in line with data protection and confidentiality.

Data collected from the questionnaires was inputted by two of the project members onto an Excel spreadsheet and subsequently analysed.

Results

A total of 135 patient responses were collected.

Pain intensity
Of the 135 patients, 5% (n=7) reported no pain, 17% (n=23) reported mild pain, 41% (n=56) reported moderate pain and 36% (n=49) reported severe pain.

Functional limitation
98% of patients reported functional limitation due to their pain (n=113). Of this group 39% (n=45) also recorded a severe pain intensity score, 43% (n=49) reported a moderate pain intensity score, 14% (n=16) reported a mild pain intensity score and 2% reported no pain.

Psychological disorders
Of the 135 patients surveyed 51% (n=70) reported a psychological disorder.
64% (n=45) of those reporting a psychological disorder belonged to the severe pain intensity group.

Of those reporting moderate pain intensity 35% (n=25) had a psychological disorder. In the mild intensity pain group 17% (n=12) had a psychological disorder. No psychological disorders were reported in the no pain group.

Conclusions

Pain experience in the local pre-surgical orthopaedic population is significant (77% moderate and severe). Those ‘complex’ patients with severe pain, strong opioid use, and psychological comorbidity are likely to benefit from a multidisciplinary pre-surgery optimisation pathway. There is national guidance reinforcing the importance of specific, focused pre-operative pain, medication, and psychological assessment. Further optimisation for some patients is likely to result in improved short and long term peri-operative outcomes, and quality of life.

There are multiple challenges associated with this service improvement. However, we have documented the need for this service locally. Over the next twelve months, we hope to develop this project and those services to meet the needs of our population, giving them an improved short and long-term experience of surgery and multidisciplinary pain management.

References

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Curtis et al. Opioid prescribing trends and geographical variation in England, 1998-2018: a retrospective database study. Lancet Psychiatry. 2019 Feb;6(2):140-150. doi: 10.1016/S2215-0366(18)30471-1. Epub 2018 Dec 20.

Simpson et al. The prescribed opioid crisis as an impetus to improve postoperative pain management. Anaesthesia. 2023 June; 78, 1062 – 1066. doi: 10.1111/anae.16054.
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Ayyad et al. Use of preoperative opioids increases duration of hospital stay following elective lower limb arthroplasty. – A snapshot of UK practice. J Orthop. 2020 Mar-Apr; 18: 162–165. Published online 2019 Nov 6. doi: 10.1016/j.jor.2019.10.022

McAnally et al. Rationale for and approach to preoperative opioid weaning: a preoperative optimization protocol Perioper Med (Lond). 2017; 6: 19. Published online 2017 Nov 22. doi: 10.1186/s13741-017-0079-y

Levy et al. An international multidisciplinary consensus statement on the prevention of opioid-related harm in adult surgical patients. Anaesthesia. 2020 Oct; 76;4. 520 – 536. doi.org/10.1111/anae.15262

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Presenting Author

Alison Gordon

Poster Authors

David Hutchins

BMBS FRCA FFPMRCA

University Hospitals Plymouth

Lead Author

Topics

  • Novel Experimental/Analytic Approaches/Tools